Read Standard 2: Assessment and future care planning

Ageing and frailty standards
Healthcare Improvement Scotland

Standard statement

Older people living with frailty experience coordinated multidisciplinary support that is responsive to changes in their life, health and care.

Rationale

Local authorities and NHS boards must work together to plan and deliver services for older people.42 Frailty services should be designed to support people to maintain independence and remain in the community as much as possible.6 This requires a fundamental shift in culture towards proactive, preventative and integrated services.17, 43, 44

Planning for a person’s care should begin at the earliest opportunity. After someone has been identified as living with frailty, they should receive an assessment to identify and address their health and care needs. Assessments should consider underlying and potentially reversible causes of frailty. They should be repeated when there are changes in health or social care needs or when the person is dying. This includes identifying and addressing sensory and communication needs.45

A Comprehensive Geriatric Assessment (CGA) is best practice for frailty assessments.27,46 It is a multidimensional and interdisciplinary diagnostic process designed to evaluate an older person’s capabilities.29 Using CGA may reduce hospital admissions and shorten the length of time a person stays in hospital.46

People should be supported to be involved as much as they choose in the care planning process. Where this is not possible, decisions should be based on the person’s best interests and what matters to them. Staff should be trained and supported to have open conversations with people about the future if their health or capacity changes.

A single integrated care plan can ensure that information is available when needed. The care plan should be accessible to all those involved. This includes the person, their unpaid carer or care partner and all relevant staff. Information about a person and their health should be shared in line with national protocols to support multiagency working.4 A single point of contact can coordinate referrals, movement between services or places of care, follow-up and review.6 This ensures that people receive the care they need from the right people at the right time.

Criteria

2.1

Health and Social Care Partnerships have a clear, system-wide strategic vision for the integrated delivery of services for older people with frailty with the involvement of health, adult social care, public health, community and voluntary sector partners.

2.2

Health and Social Care Partnerships ensure there is:

  • a dedicated multidisciplinary team responsible for the delivery and coordination of frailty services
  • clear referral pathways to the multidisciplinary team from all relevant services.
2.3

Health and Social Care Partnerships design frailty services in partnership with older people, care partners and unpaid carers using an evidence-based and evaluated service codesign approach.

2.4

People who have been identified as living with frailty in all settings receive:

  • a CGA or comparable assessment of their health and care needs
  • clear and accessible information on the outcome of their assessment and what to expect in the future.
2.5

Care plans:

  • are developed with the full involvement of people and, where they choose, their unpaid carers or care partners
  • are easily accessible to the person and, if they choose, their unpaid carers or care partners
  • are easily accessible to all relevant members of the team around the person.
2.6

People have one documented care plan detailing all relevant health and social care information including:

  • information that the person wishes staff to know about them
  • their personal goals and preferred outcomes
  • the results of health assessments and any diagnostic tests
  • social work support assessments if undertaken
  • medication reviews and prescriptions
  • discharge information from a service or hospital, if discharged
  • plans for holistic care in the last days and weeks of life for the person and those close to them
  • specific decisions about interventions and treatments in the future, including cardiopulmonary resuscitation
  • adult support and protection concerns, where appropriate.
2.7

Older people and their unpaid carers or care partners are provided with:

  • the name of a lead coordinating individual and agency or single point of contact
  • details of the roles and responsibilities of key individuals or organisations involved in their care.
2.8

Care plans are reviewed or updated if there is a change in the life, health or circumstances of a person with frailty.

2.9

Staff are fully informed about:

  • their roles and responsibility within the frailty pathway
  • the meaning of frailty assessments or screening
  • how to act on the results of frailty assessments or screening.
2.10

Staff have the training and support to participate fully in multidisciplinary team meetings and care planning.

2.11

Staff have the training and resources to meet the needs of people who may experience:

  • behavioural and psychological symptoms of a cognitive impairment or dementia
  • communication difficulties
  • neurodiversity
  • hearing or sensory loss
  • emotional distress.
2.12

Older people with frailty receive information and support to set up power of attorney where this is their choice.

What does this standard mean for...

What does the standard mean for people?

  • Assessments of your health, care and support will focus on what matters to you and what you would like to be able to do.
  • Information about your care will be written into one single plan that will be shared with you and the people who need to see it.
  • You will be supported to ask questions about what may happen in the future.
  • You can choose who should be included in discussions about you and your care.
  • Staff will support your privacy and confidentiality.

What does the standard mean for staff?

Staff, in line with roles, responsibilities and workplace setting:

  • undertake relevant frailty assessments and investigations where frailty has been identified
  • use information from frailty assessments to identify and discuss a person’s current and future care needs
  • work effectively with other members of the multidisciplinary team
  • consider a person’s experiences, values and priorities at all stages of care planning
  • recognise the importance of autonomy and the right of the individual to make informed decisions about their care
  • include any unpaid carers or care partners in discussions about a person’s care as appropriate
  • have training and skills to support discussions about future care planning
  • know when and where to refer to further support for people living with frailty.

What does the standard mean for the organisation?

Organisations:

  • plan and develop integrated services that meet the needs of their population
  • support staff to work in partnership across a multidisciplinary team
  • provide effective mechanisms to support coordination across multiagency teams
  • provide mechanisms for staff to share and access relevant health and social care information
  • integrate future care planning with other care coordination or person-centred care planning processes
  • involve care partners in care coordination and future care planning where appropriate.

Examples of what meeting this standard might look like

  • Use of tools and frameworks to support shared decision making during care planning.
  • Use of person-centred plans created and shared digitally where possible.
  • Clinical information shared as appropriate with multidisciplinary teams.
  • Future care plans that are recorded, shared and updated.
  • Assessment and identification protocols and procedures.
  • Accessible language in all documents and communication.
  • Use of communication aids and tools.